Failure to Follow Infection Control Practices During Resident Care
Penalty
Summary
Staff failed to follow infection prevention and control practices for three residents. One resident with a stage 4 pressure ulcer on the sacral region was transferred using a mechanical lift sling after the dressing and packing were removed by CNAs, leaving the wound open and exposed. The wound bled during the transfer and soiled the sling, and the resident was taken to the shower with the wound still open and in contact with the soiled sling. The dressing was not dated and was soiled prior to removal. The wound was left open throughout the shower, and the sling remained soiled with blood. The treatment nurse later provided wound care but failed to perform hand hygiene after removing gloves and before leaving the room. Another resident with an enteral feeding tube received medication and water administration from an RN who initially performed hand hygiene and donned appropriate PPE. However, after changing the split sponge and removing gloves, the RN applied tape to the split sponge without gloves and only performed hand hygiene after removing the gown and leaving the room. The DON confirmed that gloves should have been used during all care involving the enteral tube. A third resident with a suprapubic catheter had care performed by two CNAs who did not cleanse the catheter tip before replacement and allowed the catheter bag to rest on the floor. During the care process, hand hygiene was not performed between glove changes or when moving from one area of the body to another. One CNA left the room and began care for another resident without performing hand hygiene. Facility policy required hand hygiene at specific moments, including after glove removal and when moving between contaminated and clean body sites.